801
CORRESPONDENCE
Daniel B. Gould MO St. Louis Regional Medical Center St. Louis, MO 63112 REFERENCES
I Blaise GA, Nugent M, McMichan JC, Durant PAC.
Side effects of nalbuphine while reversing opioidinduced respiratory depression: report of four cases. Can J Anaesth 1990; 37: 794-7. 2 Latasch L, Probst S, Dudziak R. Reversal by nalbuphine of respiratory depression caused by fentanyl. Anesth Analg 1984; 63: 814-6. 3 Zsigmond EK, Winnie AP, Raza SMA, Wang SY, Barabas
E. Nalbuphine as an analgesic component in balanced anesthesia for cardiac surgery. Anesth Analg 1987; 66: I 155-64.
Jehovah's Witness To the Editor: in his recent letter I Dr. W. H. Noble disagrees with the decision of the Ontario Court of Appeal in the case of Malette vs Shulman. The basis for his concern was the acceptance by the Court as valid, a signed but undated and unwitnessed, pre-printed wallet card indicating that the patient, who is a Jehovah's Witness, did not wish to receive blood or blood products under any circumstances. Although the patient was unconscious at the time the physician decided to administer blood transfusions, the patient's daughter arrived at the hospital during the course of treatment and requested that the transfusions be stopped. This request was denied. Noble's proposed solution, for which he seeks a legislated basis, is that advance directives of this type should be be declared acceptable if dated ("within a reasonable period - perhaps one year") and signed by a witness. As the following personal experience clearly demonstrated, conformance with these exact requirements will not always provide assurance that the patient has understood the full implications of his/her directive. I was surprised to be made aware, just before the start of scheduled surgery, of a witnessed, dated (day of surgery) and signed "Refusal of Blood Transfusion" form (official hospital form) in the medical record of a patient ! had seen the evening before. At that time, she had not mentioned any concern about receiving blood or blood products. Fortunately the presence of this new form in the patient's record was brought to my attention before induction of general anaesthesia, allowing me the opportunity to discover that the basis for the "refusal" was that she
simply "did not like the idea of receiving someone else's blood." The patient was in fact quite prepared to receive blood or blood products, if required as part of her medical treatment. She was appalled to learn that one implication of her signing the form was the interpretation that she was prepared to die rather than to receive a blood product. The case of Malette vs Shulman continues to be the subject of general interest 2-5 and is seen as precedentsetting, with Canada-wide implications, despite the fact that it arose from the Appeal Court of one Province. The primary area of precedent in this case is the right of self-determination, including the right of a competent individual to refuse treatment which in the opinion of others is likely to be beneficial, or essential, even if death may result as a consequence of this refusal. The issue concerning the form of the advance directive, in this case, the undated, unwitnessed wallet card, although of secondary importance, also has major implications, as outlined by Noble. A third important point, which has received less emphasis in the subsequent discussion of the judgement was the specific refusal by the Court to accept the notion of"informed refusal." This element of the decision has troubling implications and appears to be in conflict with the principles of the well-established doctrine of "informed consent." The issues of advance directives for health care (living wills) and durable powers of attorney (binding arrangements for future substitute consent) are under active review in several provinces, including Manitoba. 6 I am sure that as part of these current discussions, concerns such as those expressed by Noble will be dealt with in new laws or regulations. In the meantime, we are left with both the need and the responsibility to make individual judgements on the validity and relativity of advance directives of the type subject to litigation in Malette vs Shulman, and to accept the consequences of our decisions. Douglas B. Craig MD FRCPC Department of Anesthesia University of Manitoba Chairman, Consent Committee Health Sciences Centre Winnipeg, Manitoba REFERENCES
I Noble WH. CMPA and Jehovah's Witness (Letter to
Editor). Can J Anaesth 1991; 38: 262-3. 2 Sneiderman B. The Shulman case and the fight to refuse
treatment. Humane Medicine 1991; 7: 15-21. 3 Dickens BM. Medical priority of patients' wishes (Editor-
ial). Humane Medicine 1991; 7: 7-9. 4 Senn JS. The Shulman case: a physician's viewpoint
(Editorial). Humane Medicine 1991; 7:9-1 I. 5 Trent B. Jehovah's Witnesses and the transfusion debate:
802
"We Are Not Asking for the Right to Die". Can Med Assoc J 1991; 144: 770-7. 6 Discussion Paper on Advance Directives and Durable Powers of Attorney for Health Care. Manitoba Law Reform Commission. Winnipeg, Manitoba. July, 1990.
REPLY Dr. Craig raises excellent issues. He points out that even if a patient had a dated, signed and witnessedform stating he did not wish medical treatment there would be no guarantee that the patient was "informed" about the choice he had made - a choice that very well might cost him his life. In Dr. Craig's example a patient had not been "informed" about the consequences of her decision to refuse blood. When informed that blood refusal meant she was prepared to die rather than receiving someone else's blood, she stated she "did not like the idea of receiving someone else' s blood" but would accept blood to save her life. A life-threatening decision not to accept blood was changed when the clear meaning of that decision was spelled out. Dr. Craig raises the problem of "informed refusal." If physicians cannot perform medical procedures without "informed consent" it would appear reasonable that patients should be "informed" about the consequences of their decision before they refuse treatment. None of these issues was adequately considered in the case of Malette vs Shulman. My proposal (that at the very least, and in order to be legally binding, a patient must be required to have a signed, witnessed and recently dated form stating his wish not to accept medical treatment) only gives us assurance that the patient has thought about the problem recently. This form will not protect patients from incorrect information. This would be a bare minimum standard that does not exist today. But as Dr. Craig points out even that standard would not have helped his patient. To improve on the signed, witnessed and recently dated form Dr. Craig suggests an "informed refusal" form might help. For those of us who believe that "informed consent" is not possible, scepticism about the value of "informed refusal" comes easily. In fact Dr. Craig's patient illustrates the problem of "informed refusal." His patient was "informed" by medical personnel about the "refusal" and yet did not understand the meaning of the "informed refusal." If medical personnel can't obtain a correct "informed refusal" how well will laymen fare and who else is there to obtain this "informed refusal" ? Living Wills represent the next attempt to inform physicians of the incompetent patient's wishes for medical treatment. Unfortunately, they are tainted with the same brush as "'informed consent" and "informed refusal." Has the patient who creates a living will really been "informed" about the choices that a physician may have to make on his behalf when the patient is incompetent? I suggest the chances that the patient has been informed about the particular choices to be made are small, i f that is true, these documents should not be legally binding but only considered as guidelines to help the physician make difficult choices. Anaesthetists and Intensivists frequently must make decisions about what medical care a patient would want if he were competent to make the decision. I am not satisfied (and probably never will be) with the decision-making process. The objective should be to provide the medical care that the patient wishes to
CANADIAN J O U R N A L OF A N A E S T H E S I A
receive or not to receive, with full knowledge of the probable consequences. How can that be best achieved? in an ideal world "informed refusal" and "living wills" would provide a helpful solution. But Dr. Craig's case illustrates how "informed refusal" (if legally binding) also fails to provide the patient with the medical care he desires. What is the best solution? I would be interested in physicians' opinions on whether (a) the current status, (b) a signed, recently dated, witnessed card, (c) informed refusal and~or (d) other proposals would best help the physician in our dilemma of how to provide the care the patient wants even when he is incompetent. W.H. Noble Mo FRC~
St. Michael's Hospital University of Toronto
CORRESPONDENCE
Daniel B. Gould MO St. Louis Regional Medical Center St. Louis, MO 63112 REFERENCES
I Blaise GA, Nugent M, McMichan JC, Durant PAC.
Side effects of nalbuphine while reversing opioidinduced respiratory depression: report of four cases. Can J Anaesth 1990; 37: 794-7. 2 Latasch L, Probst S, Dudziak R. Reversal by nalbuphine of respiratory depression caused by fentanyl. Anesth Analg 1984; 63: 814-6. 3 Zsigmond EK, Winnie AP, Raza SMA, Wang SY, Barabas
E. Nalbuphine as an analgesic component in balanced anesthesia for cardiac surgery. Anesth Analg 1987; 66: I 155-64.
Jehovah's Witness To the Editor: in his recent letter I Dr. W. H. Noble disagrees with the decision of the Ontario Court of Appeal in the case of Malette vs Shulman. The basis for his concern was the acceptance by the Court as valid, a signed but undated and unwitnessed, pre-printed wallet card indicating that the patient, who is a Jehovah's Witness, did not wish to receive blood or blood products under any circumstances. Although the patient was unconscious at the time the physician decided to administer blood transfusions, the patient's daughter arrived at the hospital during the course of treatment and requested that the transfusions be stopped. This request was denied. Noble's proposed solution, for which he seeks a legislated basis, is that advance directives of this type should be be declared acceptable if dated ("within a reasonable period - perhaps one year") and signed by a witness. As the following personal experience clearly demonstrated, conformance with these exact requirements will not always provide assurance that the patient has understood the full implications of his/her directive. I was surprised to be made aware, just before the start of scheduled surgery, of a witnessed, dated (day of surgery) and signed "Refusal of Blood Transfusion" form (official hospital form) in the medical record of a patient ! had seen the evening before. At that time, she had not mentioned any concern about receiving blood or blood products. Fortunately the presence of this new form in the patient's record was brought to my attention before induction of general anaesthesia, allowing me the opportunity to discover that the basis for the "refusal" was that she
simply "did not like the idea of receiving someone else's blood." The patient was in fact quite prepared to receive blood or blood products, if required as part of her medical treatment. She was appalled to learn that one implication of her signing the form was the interpretation that she was prepared to die rather than to receive a blood product. The case of Malette vs Shulman continues to be the subject of general interest 2-5 and is seen as precedentsetting, with Canada-wide implications, despite the fact that it arose from the Appeal Court of one Province. The primary area of precedent in this case is the right of self-determination, including the right of a competent individual to refuse treatment which in the opinion of others is likely to be beneficial, or essential, even if death may result as a consequence of this refusal. The issue concerning the form of the advance directive, in this case, the undated, unwitnessed wallet card, although of secondary importance, also has major implications, as outlined by Noble. A third important point, which has received less emphasis in the subsequent discussion of the judgement was the specific refusal by the Court to accept the notion of"informed refusal." This element of the decision has troubling implications and appears to be in conflict with the principles of the well-established doctrine of "informed consent." The issues of advance directives for health care (living wills) and durable powers of attorney (binding arrangements for future substitute consent) are under active review in several provinces, including Manitoba. 6 I am sure that as part of these current discussions, concerns such as those expressed by Noble will be dealt with in new laws or regulations. In the meantime, we are left with both the need and the responsibility to make individual judgements on the validity and relativity of advance directives of the type subject to litigation in Malette vs Shulman, and to accept the consequences of our decisions. Douglas B. Craig MD FRCPC Department of Anesthesia University of Manitoba Chairman, Consent Committee Health Sciences Centre Winnipeg, Manitoba REFERENCES
I Noble WH. CMPA and Jehovah's Witness (Letter to
Editor). Can J Anaesth 1991; 38: 262-3. 2 Sneiderman B. The Shulman case and the fight to refuse
treatment. Humane Medicine 1991; 7: 15-21. 3 Dickens BM. Medical priority of patients' wishes (Editor-
ial). Humane Medicine 1991; 7: 7-9. 4 Senn JS. The Shulman case: a physician's viewpoint
(Editorial). Humane Medicine 1991; 7:9-1 I. 5 Trent B. Jehovah's Witnesses and the transfusion debate:
802
"We Are Not Asking for the Right to Die". Can Med Assoc J 1991; 144: 770-7. 6 Discussion Paper on Advance Directives and Durable Powers of Attorney for Health Care. Manitoba Law Reform Commission. Winnipeg, Manitoba. July, 1990.
REPLY Dr. Craig raises excellent issues. He points out that even if a patient had a dated, signed and witnessedform stating he did not wish medical treatment there would be no guarantee that the patient was "informed" about the choice he had made - a choice that very well might cost him his life. In Dr. Craig's example a patient had not been "informed" about the consequences of her decision to refuse blood. When informed that blood refusal meant she was prepared to die rather than receiving someone else's blood, she stated she "did not like the idea of receiving someone else' s blood" but would accept blood to save her life. A life-threatening decision not to accept blood was changed when the clear meaning of that decision was spelled out. Dr. Craig raises the problem of "informed refusal." If physicians cannot perform medical procedures without "informed consent" it would appear reasonable that patients should be "informed" about the consequences of their decision before they refuse treatment. None of these issues was adequately considered in the case of Malette vs Shulman. My proposal (that at the very least, and in order to be legally binding, a patient must be required to have a signed, witnessed and recently dated form stating his wish not to accept medical treatment) only gives us assurance that the patient has thought about the problem recently. This form will not protect patients from incorrect information. This would be a bare minimum standard that does not exist today. But as Dr. Craig points out even that standard would not have helped his patient. To improve on the signed, witnessed and recently dated form Dr. Craig suggests an "informed refusal" form might help. For those of us who believe that "informed consent" is not possible, scepticism about the value of "informed refusal" comes easily. In fact Dr. Craig's patient illustrates the problem of "informed refusal." His patient was "informed" by medical personnel about the "refusal" and yet did not understand the meaning of the "informed refusal." If medical personnel can't obtain a correct "informed refusal" how well will laymen fare and who else is there to obtain this "informed refusal" ? Living Wills represent the next attempt to inform physicians of the incompetent patient's wishes for medical treatment. Unfortunately, they are tainted with the same brush as "'informed consent" and "informed refusal." Has the patient who creates a living will really been "informed" about the choices that a physician may have to make on his behalf when the patient is incompetent? I suggest the chances that the patient has been informed about the particular choices to be made are small, i f that is true, these documents should not be legally binding but only considered as guidelines to help the physician make difficult choices. Anaesthetists and Intensivists frequently must make decisions about what medical care a patient would want if he were competent to make the decision. I am not satisfied (and probably never will be) with the decision-making process. The objective should be to provide the medical care that the patient wishes to
CANADIAN J O U R N A L OF A N A E S T H E S I A
receive or not to receive, with full knowledge of the probable consequences. How can that be best achieved? in an ideal world "informed refusal" and "living wills" would provide a helpful solution. But Dr. Craig's case illustrates how "informed refusal" (if legally binding) also fails to provide the patient with the medical care he desires. What is the best solution? I would be interested in physicians' opinions on whether (a) the current status, (b) a signed, recently dated, witnessed card, (c) informed refusal and~or (d) other proposals would best help the physician in our dilemma of how to provide the care the patient wants even when he is incompetent. W.H. Noble Mo FRC~
St. Michael's Hospital University of Toronto
